Recent years have been marked by a number of high profile international doping scandals. Doping is an ethical dilemma that rocks the very base of competitive sport. The following article examines these ethical considerations and take an in depth look at banned substances, their abuse and methods to combat this in professional sport.
‘When humans compete against one another, either in war, in business, or in sport, the competitors, by definition, seek to achieve an advantage over their opponent. Frequently they use drugs and other substances to gain the upper hand. Furthermore, there have always been individuals who in the pursuit of victory have transcended social norms.’ Charles E. Yesalis
While doping has gained more recognition and press in recent times it is by no means a current phenomenon. The use of drugs in sports has had a long and well documented history going as far back as Greek and Roman times where Early Olympians used extracts of mushrooms and plant seeds and Gladiators took substances to make their fights more vigorous and bloody.
In the last third of the nineteenth century, the use of stimulants among athletes was commonplace, and moreover, there was no attempt to conceal drug usage. Swimmers, distance runners, sprinters and cyclists used a wide assortment of drugs including strychnine, cocaine, caffeine and alcohol, to gain an edge over their opponents. 1886 marked the first recorded doping death with cyclist Arthur Linton overdosing on trimethyl. This was followed, in 1904, by the near death of Marathon runner Thomas Hicks at the Olympics in St Louis after mixing brandy and strychnine.
The 1930s marked the advent of Amphetamines which were created by the military to assist pilots and soldiers. By 1933 the word doping had become part of the English language. At the Rome Olympics (1960) amphetamine-taking Danish cyclist Knut Jensen collapsed, fractured his skull and died. This was followed in the 1967 Tour de France by another amphetamine death when Britain’s Tommy Simpson died of dehydration as a result. In response to this, Jacques Anquetil, a five-time winner of the Tour de France, stated: ‘For 50 years bike racers have been taking stimulants. Obviously we can do without them in a race, but then we will pedal 15 miles an hour [instead of 25]. Since we are constantly asked to go faster and to make even greater efforts, we are obliged to take stimulants’
In the 1950s the Soviets begin to use male hormones and the commencement of systematic use of anabolic steroids in sport has been largely attributed to the massively successful Soviet weightlifting teams in the early 1950s. Statistical analysis of the performance of the Soviet lifters during this period is consistent with anabolic steroid usage. The 1976 Olympics marked The culmination of a decades long series of documented clinical trials in The Germany Democratic Republic utilizing anabolic steroids on their athletes. It is estimated that some 9,000 former athletes, perhaps more, were doped, often unwittingly, in the program. Due to obvious ethical constraints this to date, remains one of the few documented, systematic reviews of performance enhancing drugs. Under a national plan, “State Plan 14.25,” the East German government “called for the administering of male hormones to male and female athletes.” The swimmers, and many other Olympic athletes, took the German manufactured steroid Oral-Turinabol, often believing they were vitamins. As a result in 1976 East German swimmers won 11 out of 13 Olympic events. The documented effects of this program down the line include: cancer, ovarian cysts, liver damage, heart disease, infertility and other ailments. Victims of the East German doping program were financially compensated after an extended legal battle in 2000. It may be a rather cynical sentiment, but doping trends in professional sport seem to suggest athletes will disregard the health risks in order to excel. It would be interesting to see how many of the athlete’s involved, would have willingly chosen to be part of the program to gain the high level of performance documented in the studies.
1972 marked a new era for doping when a Swedish doctor, Björn Ekblom, pioneered ‘blood doping’ which entailed removing blood, increasing the concentration of red blood cells in a centrifuge and then restoring it through transfusion. This obviously enhanced the oxygen transportation capacity of the blood. This was given further impotence in the late 80’s with the development of Erythropoietin (EPO) which effectively enhances red blood cell production.
And so begins a fairly consistent tale of drug test failures of professional, high profile athletes. Notables include: Ben Johnson – Seoul Olympics (1988). Diego Maradona – Soccer World Cup (1994). Linford Christie (1999)
The 2000s are dominated by numerous high profile cycling busts, culminating in the ban for life and stripping of all titles, of 7 time Tour de France winner, Lance Armstrong. His doping strategies were termed “the most sophisticated, professionalized and successful doping program cycling has ever seen” by the US anti doping agency and highlight the extent to which professional sport people are willing to go in order to excel.
Estimates of doping prevalence varies massively according to the research. The simple answer is nobody knows. Estimates range from the World-Anti Doping Agency (WADA) official statistic of 2% right up to 35% depending on the approach. When athletes are asked about doping statistics, they guess around 10%. A recent German study showed that actual doping rates were eight times the positive test rate, so in the case of WADA’s 2% one could estimate a rate of 16% of athletes doping. Based on WADA’s, likely very low statistics, that means at least 200 (of the 10,000 or so) athletes in the London Olympics were doping.
If the German statistics hold true, this figure moves to 1600.
The International Association of Athletics Federations (IAAF) became the first International Sporting Federation to prohibit doping, doing so in 1928. However, soon after World War II with the advent of amphetamines, it became clear that many athletes in a wide range of sports were using drugs to enhance their performance. The aforementioned death of cyclists 1960 and 1967, as a result of drugs, brought doping into the public spotlight. as a result, the International Olympic Committee approved a ban on doping in 1968. The Committee defined the first list of Prohibited Substances and the first tests for stimulants were performed at the Winter Olympics in 1968. Steroids only became detectable in 1974. At the same time International Sports Federations initiated doping controls and the IAAF became the first to perform out-of-competition tests. Subsequently national Anti-Doping Agencies instituted doping controls and testing within their borders. Our local agency, the South African Institute for Drug Free Sport is responsible for testing within South Africa.
On 08/07/1998 the world was rocked by a doping scandal when Willy Voet, a masseur for the Festina cycling team was stopped at the Franco-Belgium border during the Tour de France. He was found to be in possession of more than 400 doping products. As a result of this and numerous other doping scandals, The World Anti- Doping Agency (WADA) was created in 1999 to harmonize and strengthen anti-doping actions and rules across all sports and countries. WADA also took over the role of publishing the list of Prohibited Substances, which is continually under review and formally updated on 1 January each year.
Doping Testing Procedures
As mentioned above the national anti-doping agencies are responsible for the testing procedures. They develop a Test Distribution Plan according to:
Physical demands of the sport and possible performance-enhancing effect that doping may elicit
Available doping analysis statistics
Available research on doping trends
The history of doping in the sport and/or discipline
Training periods and the competition calendar
Information received on possible doping practices
Athletes may be tested either in or out of competition. An example of how athletes would be selected for in competition or event testing could be: Placed finishers, such as the top three finishers and randomly selected athletes, such as 5th, 7th, 12th, 18th, 19th, etc. Out of competition testing occurs according to the above criteria of the Test Distribution plan. Athletes who are part of the Testing Pool must provide a 60-minute time slot each day between 6 a.m. – 11p.m. Athletes, have to be available for testing without any advance notice in an out-of-competition setting and are subject to testing 365 days a year and do not have “off-seasons” or cutoff periods in which testing does not occur.
Currently Blood and urine samples are taken for lab testing. Through regular testing an athlete’s biological passport is created. This is basically an accurate Indicator of the athlete’s personal parameters. It is the equivalent of a physiological fingerprint. This allows anti-doping agency to quickly recognize if an athlete is utilizing performance enhancing substances when their test results stray outside of their normal criteria. Laboratory results that compared samples taken during Lance Armstrong’s return to cycling in the 2009 Tour de France to his biological passport, strongly point to his use of blood manipulation, including EPO or blood transfusions.
Anti-doping agencies are increasingly utilizing ‘intelligence’ gained from team members, other athletes, medical staff etc. to optimize their testing resources and to convict athletes transgressing the rules. Lance Armstrong is a case in point. The current evidence against Armstrong derives largely from the fact that 12 of his former teammates and support team gave evidence that Armstrong was centrally involved in systematic doping in the teams he was involved in. He either admitted to them, or they directly observed him using and encouraged them to use: erythropoietin, blood transfusion, cortisone, testosterone and human growth hormone from 1996 to 2005. For this, Armstrong was charged by the US Anti-Doping Agency with possession, distribution, use, administration and trafficking in prohibited substances. Additionally, he was charged with assisting, encouraging, aiding, abetting, covering up and other complicity in anti-doping rule violations. Olympic Gold medallist Marion Jones is another example. She was tested as frequently as Armstrong, but did not return a single positive test. She was found guilty and banned as a result of the BALCO scandal which uncovered systematic doping, largely by US athletes, using “designer steroids” that avoided detection. This wes only discovered through good intelligence work.
Common Substances: effects and side effects
In 2008, Bernard Kohl who placed 3rd in the Tour de France tested positive for CERA (EPO) and was banned for 2 years. After being found guilty, Kohl handed over his ‘doping diary’, revealing the extent and level of doping in professional cycling.
“I was tested 200 times during my career, and 100 times I had drugs in my body,” he said, according to the New York Times. “I was caught, but 99 other times, I wasn’t. Riders think they can get away with doping because most of the time they do. Even if there is a new test for blood doping, I’m not even sure it will scare riders into stopping. The problem is just that bad.”
“People know in cycling that’s it’s not possible to win the Tour de France without it. It’s three weeks, 3,000 km and you climb Mount Everest four times. That’s just not possible.”
When asked in 2010, whether Alberto Contador had used doped to win the Tour de France, Kohl wouldn’t directly speculate but noted that the average speeds ridden at the Tour might cause one to think so.
“Floyd Landis won the Tour de France and his average speed was 40 kph,” Kohl said. “This year it was Contador and it was also about 40. It was nearly the same average speed. Landis was doped.”
Interestingly, after a protracted battle, on february 6 this year, Contador was stripped of his 2010 title after testing positive for Clenbutarol.
In a scientifically designed doping program aimed at maximally enhancing performance and more importantly avoiding detection, Kohl’s admitted to using blood transfusions, EPO, anabolic steroids, cortisone, human growth hormone, insulin, HCG, thyroid hormone, and designer testosterone.
Substances are prohibited if they meet at least two of the following criteria:
- Potential to enhance sports performance
- Actual or potential health risk to an athlete
- Its use violates the spirit of sport.
The following list is far from exhaustive but gives a brief glimpse into some of the commonly used doping substances and their effects / side effects.
ACTH or Corticotrophin
ACTH or Adreno-cortical stimulating hormone, stimulates the adrenal grand to produce cortisol, a natural steroidal hormonal with multiple physiological effects including anti-inflammatory properties to facilitate recovery.
Possible side effects: Water retention, edema, Hyperglycemia, Blood hypertension, Osteoporosis, Decrease in resistance to infections
Amphetamines were first synthesized in 1887. The effects of the drug include a sense of well-being, a decrease in the perception of fatigue, an increase in self-confidence, in motor function and a decrease in appetite. As there are no positive long term effects, amphetamines are usually consumed just prior to competition. Due to their effects (perceived and real) they are very addictive.
Possible side effects: Confusion, Tremors, Delirium, Psychosis, Paranoid delirium, Insomnia, Nausea, Vomiting
Anabolic substances (steroids)
This class of doping substances includes all steroids that possess anabolic properties including testosterone. This in essence means they cause a marked, non-isolated increase in the muscular mass. In sports such as weightlifting and bodybuilding, these substances are often used in weeks preceding a competition. Cyclists seem to use anabolic substances in smaller quantities to facilitate muscular recovery. The side effects associated with the extensive of anabolic steroids have been scientifically observed and documented:
Possible side effects: Anomalies in the function of the liver and liver cancer, Hypercholesterolemia, prostate cancer, myocardial infarction, Diabetes, testicular atrophy, Feminization : gynecomastia (breast development in men) and high-pitched, castrato-like voice, Behavioral modifications including aggressiveness and groundless violence, Acne, Muscular rupture, Hair loss, Irreversible virilization or masculinization in women including Husky voice and Hirsutism (appearance of body hair in regions that are normally hairless.
They are beta receptor antagonists that prevent binding of adrenaline in adrenergic beta receptors. Beta blockers can be misused in certain sports, for example shooting, archery and golf to control the effects of nervousness, hand tremor and high heart rate
Possible side effects. The undesirable effects of beta-blockers stem from their inhibitory properties. Issues may include: bronchial spasms, Hypoglycemia, Troubles with digestion, Cardiac insufficiency, Cardiac rhythm problems
Codeine, opiates and other morphine derivatives
The use of pain killers is frequent in all sports. Professional obligations often necessitate competing with injuries.
Possible side effects: Addiction, Nausea, Vomiting, Withdrawal syndrome
Corticosteroids are potent systemic anti-inflammatory and immunosuprresant. There is a long and well documented history of corticosteriod abuse amongst sport people.
Possible side effects: side effects are numerous and serious.
Erythropoietin (often shortened to EPO) is a naturally occurring hormone, secreted by the kidneys, whose function is to regulate red blood cell production. It effectively stimulates bone marrow to produce more red blood cells (RBC) and therefore haemoglobin. The use of EPO started in the 1980’s as a quicker, cleaner alternative to blood doping. EPO is most commonly used amongst endurance athletes as a higher RBC count means better oxygen transportation and so a higher rate of aerobic respiration and decreased fatigue.
EPO is used in medical practice in cases of severe anemia and during treatment of chronic renal insufficiency, such as in dialysis patients.
Possible side effects: Increased viscosity of the blood with increases the risk of heart attack and stroke. The lack of knowledge regarding dosage and side effects of EPO has been linked to the death of a number of competitive cyclists in the late 80’s.
Chorionic gonadotropin (hCG)
This natural product is classified as a stimulant because it causes an increase in the production of endogenous testosterone. When exogenous anabolic substances are put into the male body, natural negative-feedback loops cause the body to shut down its own production of testosterone. This causes testicular atrophy and decreased endogenous testosterone. hCG is commonly used during and after steroid cycles to maintain and restore testicular size as well as normal testosterone production.
Possible side effects: largely related to excessive testosterone production so similar to anabolic sustances The associated dangers depend on dosage and vary according to sex. May also include Hypertension thrusts when the substance is introduced too rapidly, Vascular thrombosis, Convulsions.
Human growth hormone (hGH)
Growth hormone is used for the anabolic effects. It is thought to increases muscle mass and strength, and helps hasten recovery and repair Uncertainties remain about the safety of exogenous hGH. We still do not know what influence it may have on normal individuals, even though there is a good deal of information about side effects of endogenous hGH hyper secretion in acromegaly. This condition has an associated 50% mortality at age 50 and 89% mortality at age 60. hGH found on the black market may be extractive growth hormone (extracted from the pituitary gland of corpses). The method used to purify the hormone does not guarantee the removal of other biological molecules which can cause adverse reactions
Possible side effects: Tumefaction of soft tissue, arthritis, Thickening of the skin, Hirsutism (hair growth over the entire body), Increase in perspiration, Peripheral neuropathies, Myopathies, Hypertrophy of the viscera : spleen, salivary glands, liver, kidneys, heart, Glucose intolerance / diabetes mellitus
Although it’s more usually associated with the regulation of blood glucose, the hormone insulin can also act as a powerful anabolic agent, helping to increase glycogen synthesis and lean muscle mass. Insulin is commonly used in conjunction with the anabolic steroids, obviously due to the anabolic effects but also to decrease the insulin resistance caused by anabolic steroids and growth hormones.
Possible side effects: Tremors, anxiety, myocardial infarction, Numerous drug interactions
Overdose: hypoglycemia may result from poorly estimated insulin dosage, a mistake in feeding or a unforeseen physical effort that is not compensated. The symptoms of hypoglycemia include hunger, sweat, asthenia, tremors, confusion, problems with vision, headaches, etc. Unless treated promptly, hypoglycemia may result in a coma.
Thyroid hormone drugs
These have mainly positive effects as long as the dosage is not increased too quickly and is not oversized, in which cases symptoms that are similar to hyperthyreosis appear, such as heart palpitation, arrhythmias, diarrhea, emaciation, decrease in temperature tolerance, insomnia, agitation, and even psychoses [2, 3].
For people with latent heart diseases, adverse heart related effects (arrhythmias, heart infarct) can be perilous . Before starting a thyroid gland treatment, the doctor should carefully review the patient’s health including the functioning of the heart. The risks related to the treatment can thus be determined.
Prolonged thyroxine overdosing increases the risk of osteoporosis. Perilous agranulocytosis (lowered white blood cell count) is found in 0.1 to 0.5 percent of patients .
Acute large thyroxine doses lead to thyrotoxicosis. The symptoms are high body temperature, failing heart functioning and coma . Overdosing of thyroid gland hormones have led to deaths.
Drug effects in sport
With the lack of research into many aspects of doping one may assume that numerous athletes are utilizing banned substances in response to a fear that their fellow competitors have a marked advantage over them. Their are however a few fascinating studies that cast light on just how effective doping may be.
Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government Werner W. Franke1* and Brigitte Berendonk2 Clinical Chemistry 43:7 1262–1279 (1997)
“Several classified documents saved after the collapse of the German Democratic Republic (GDR) in 1990 describe the promotion by the government of the use of drugs, notably androgenic steroids, in high performance sports (doping). Top-secret doctoral theses, scientific reports, progress reports of grants, proceedings from symposia of experts, and reports of physicians and scientists who served as unofficial collaborators for the Ministry for State Security (“Stasi”) reveal that from 1966 on, hundreds of physicians and scientists, including top-ranking professors, performed doping research and administered prescription drugs as well as unapproved experimental drug preparations. Several thousand athletes were treated with androgens every year, including minors of each sex. Special emphasis was placed on administering androgens to women and adolescent girls because this practice proved to be particularly effective for sports performance. Damaging side effects were recorded, some of which required surgical or medical intervention. In addition, several prominent scientists and sports physicians of the GDR contributed to the development of methods of drug administration that would evade detection by international doping controls.”
As mentioned previously this remains the only, large scale, scientific reviews of doping in professional sport. It provides obvious graphical data of the effect of androgynous substances on performance of athletes, particularly in the throwing disciplines.
Effects of an androgenic-anabolic steroid, Oral-Turinabol, on the shot-put performance (in meters, y-axis) of a female athlete (code identification 1/68 in a, 1/69 in b, and 1/72 in c) The blocks on the x-axis signify ‘cycles’ of doping with resultant spikes in throwing performance
Decreased performances in women’s strength-dependent events worldwide, after implementation in 1989 of some (though still insufficient) out-of-competition doping controls: cordinates present meters of performance of the world best (upper curve) and the average of the ten best (lower curve) athletes in the javelin throw (A), discus throw (B), and shot-put (C) for the years 1987–1993.
This visible decline in throwing and strength related sport performance after the introduction of random out-of-competition testing is obviously as a result of decreased doping . Decreased is the operative word; today’s best athletes are unlikely to be free from doping but are just doping less and better than previously. Another interesting discovery by GDR scientists was that “androgenic initiation” has permanent effects in girls and women and hence once a higher performance level is reached it does not return to pre-steroid levels on cessation if the doping. In this regard, many of today’s top athletes still profit from their previous doping.
Medvedyev, et.al. did a statistical analysis of the world records established in weightlifting particularly in the snatch and the clean and jerk. The results showed that the rate of improvement of world records in weightlifting accelerated from the period 1967 – 1973 up to 1980. This was followed by an even faster rate of improvement from 1980 up to 1988. The only plausible reason was the widespread use of performance enhancing drugs.As with the throwing disciplines, in the wake of stricter, more sophisticated testing procedures established in 1989 there was an obvious drop in the results at the major world events of 1990 and 1991.
J J Thomsen, et al of the Copenhagen Muscle Research Centre did an interesting study on the effects of EPO on a group of non-professional cyclists. Their results were an eye opener. ‘With rHuEpo (recombinant human erythropoietin) treatment VO2max increased (P<0.05) by 12.6 and 11.6% in week 4 and 11, respectively, and time-to-exhaustion (80% VO2max) was increased by 54.0 and 54.3% (P<0.05) after 4 and 11 weeks of treatment, respectively’
“The use of drug use in sport is both unhealthy and contrary to the ethics of sport. It is necessary to protect the physical and spiritual health of athletes, the values of fair play and of competition, the integrity and the unity of sport, and the rights of those who take part in it at whatever level.” IOC, 1990
“Equal conditions for all” definition of fair play, Oxford English Dictionary.
Beyond the health risks examined earlier, drug use by athletes clearly violates sporting ethical considerations and this remains the largest focus of the anti doping movement. Although it appears that athletes have been using performance enhancing substances for as long as sport has existed, the drive to professionalism and increased financial incentives has certainly blurred the lines. Increasingly athletes seem to have a “cheat-or-lose” philosophy.
The benefit of sport include: character building, dedication, perseverance, endurance and self-discipline. Sport helps us learn from defeat as much as from victory, and team sports facilitate co-operation, imparting moral and social values. It is also about integrating us as individuals, to bring about a healthy society. These considerations have clearly taken a back seat in numerous professional sporting settings. In present day professional sport the pressured on all concerned is immense. An athlete nowadays is faced with meeting expectations of the coach, teammates, family, friends, sponsors and spectators. Coaches are also faced with similar pressure.
Beyond doping being against the ethical ‘idea’ of sport, it goes against the philosophy of “equal conditions for all”. This means sport moves beyond skill levels, training etc. and becomes about who can throw the most resources at the problem. Sport is in essence replaced by a competition between doctors and biochemists and the regulating authorities! One of the more striking ethical considerations as health professionals is how complicit doctors and other health practitioners are in the procurement and provision of banned substances. The violates the basic ethical principles of medicine in many ways. Doctors are willingly providing substances that may well have negative implications on athletes
Pharmaceutical companies are also likely to blame, with many professionals having access to products before they come on the market. There has also been calls from WADA for pharmaceutical companies to place markers in their drugs to assist with testing, to no avail. Although cynical, this likely has a financial reason. In Italy, sales of a certain EPO drug far exceed documented cases of heart disease!
There is an emerging counter argument for the legalization of drugs in sport. Key points of this argument include:
- Leveling of the playing field
- Higher level of performance and increased spectatorship.
- Better control of doping substances
This argument is totally incongruent with the ethical considerations cited earlier. From a health perspective, even if doping were legalized there still would have to be some forms of control and athlete’s would likely still be pushing the boundaries to gain competitive advantage.
The incidence of doping in sport likely exceeds estimations many fold. With increasing incentive to win, both from a fame and financial perspective, the anti-doping sector faces an uphill battle. Until punishments become truly prohibitive (lifetime ban for all guilty parties) and until sporting powers that be stop turning a blind eye and fully co-operate, it is likely to continue to be a battle of resources between sports people and anti-doping agencies.
by Iain Sykes (physiotherapist)
Iain Sykes Physiotherapy
Cape Town South Africa